Male circumcision employed as a prophylactic surgical intervention
for HIV transmission reduction has been publicized in the media
following recent results from observational trials conducted in Africa.
Yet in all of the discussions concerning circumcision as a public health
initiative, including a cost analysis performed on circumcision as a
prophylactic for reducing HIV transmission in Africa, none estimates the
endeavor's scope or cost. Given the scale of the economics involved
in and the number of competing strategies available for addressing the
HIV epidemic, funding and cost effectiveness are vital concerns in the
field. This raises the question of which treatments and methodologies to
fund, or not. In this study, we use circumcision costs, census, and
demographic data available from government agencies and other published
sources to estimate the cost to circumcise all HIV-negative African
adult males, including costs of complications. We compare that cost to
another androcentric penile alteration: using condoms (including their
purchase and distribution costs). Our findings suggest that behavior
change programs are more efficient and cost effective than surgical
procedures. Providing free condoms is estimated to be significantly less
costly, more effective in comparison to circumcising, and at least 95
times more cost effective at stopping the spread of HIV in sub-Saharan
Africa. In addition, condom usage provides protection for women as well
as men. This is significant in an area where almost 61% of adults living
with AIDS are women.

Keywords: circumcision, HIV/AIDS, condoms, health costs, Africa

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The recent announcement by UNAIDS regarding revised figures for the
prevalence and incidence of HIV on a global scale has promoted
discussion among various stakeholders on the best possible resource
commitments and methods to expand access to both prevention and
treatment for HIV/AIDS (UNAIDS, 2007a). With an established sense of
urgency over the past decades, researchers have looked to identify novel
and efficacious methods to reduce transmission. These range from
established and proven methods such as education, programs focusing on
high-risk individuals, and barrier-based methods, such as condom usage
(Weller, 2003), to novel and still controversial (Dowsett, 2007)
methods, such as male circumcision.

Sub-Saharan Africa remains the region with the highest number of
infected persons and prevalence rate. Some observational studies (Weiss,
2000; Auvert, 2005) have claimed that circumcision offers protection to
the male partner in the reduction of female-to-male transmission of
sexually transmitted infections. Circumcision as a possible method to
protect against HIV has generated much publicity (Myers, 2007). However,
it is important from policy, practice, and efficacy viewpoints to
analyze the cost effectiveness of circumcision versus that of a proven
benchmark such as condom usage in combination with social intervention
practices.

The magnitude of the problem of AIDS in sub-Saharan Africa is
illustrated by Table 1, compiled from UNAIDS (2007a) and United States
census data (Velkoff, 2007). The prevalence of HIV in sub-Saharan Africa
among adults has been reduced to 5.0% [95% CI: 4.6-5.5%], down from 6.1%
[95% CI: 5.4-6.8%] in 2006 (UNAIDS, 2007a). Given the magnitude of this
problem, multiple approaches to reduce incidence and impact can and must
be tried, but with a view to maximizing resource application
effectiveness and efficiency.

Male circumcision, a medically and ethically controversial
procedure (Dowsett, 2007), has been proposed as a mode of reduction of
HIV transmission from women to men (Williams, 2006). A study examining
the cost-effectiveness of this surgical procedure concluded that, in the
environment in which one of the studies supporting circumcision was
conducted, the procedure was a cost-effective approach (Kahn, 2006).
However, questions remain about the risk conclusions arrived at in that
study (Kalichman, 2007). Based on the available clinical evidence,
circumcision cannot be shown to prevent transmission to women,
transmission of HIV among men who have sex with men, transmission via
intravenous drug use, or pre-, peri-, or post-natal transmission
(Dowsett, 2007; Millett, 2007). The conclusions need to be extended to a
continental scale in Africa, rather than a localized provincial level.
Cost estimates, risk, and prevalence factors need to be updated in light
of more representative data.

Even if all African adult males were circumcised today (and its
real-world effectiveness to stop HIV proves to be as high as purported
in recent controlled studies), over the next 10-year period it would
reduce the number of HIV cases in sub-Saharan Africa by only eight
percent, with a one percent reduction of deaths (Williams, 2006).

In this evaluation, we applied the methods developed by Kahn (2006)
and extended them from a local application in a single province
(Gauteng, South Africa) to a sub-Saharan environment. In Kahn's
study, cost-effectiveness was modeled for 1,000 circumcisions performed
within a general adult male population. Intervention costs included
performing circumcision and treatment of adverse events. HIV prevalence
was estimated from published estimates and incidence among susceptible
subjects assuming a steady-state epidemic. Effectiveness was defined as
the number of HIV infections averted.

We estimated costs per procedure for male circumcision and updated
these using complication rates reported in an environment where higher
rates of circumcision prevail and trained medical practitioners (doctors
and nurses) and traditional providers performed the procedure (Okeke,
2006). Calculations and comparisons used circumcision costs, census, and
demographic data available from government agencies and published
sources to estimate the cost to circumcise all HIV-negative, African
adult males, including subsequent complication costs, using available
data. We compared that cost to another androcentric method of penile
alteration: using condoms (including their purchase and distribution
costs). To facilitate consistent comparison, we gratefully adopted a
number of the procedure ranges and assumptions given in Kahn (2006).
However, the complication rate cited for short-term mildly adverse
events, short-term adverse events, and long-term events required
updating.

Circumcision complication costs should be factored into a realistic
cost-effectiveness estimate since they are a real cost of such a plan.
In developed countries, complication rates may be from 20.2% and as high
as 55%, as one longitudinal study concluded (Patel, 1966). However, the
rate varies greatly due to differences in what conditions observers
choose to identify as complications and over what time frame they
observed the patient. Complications are more frequent in rural clinics
or when performed by traditional circumcision practitioners. A study of
mass circumcision practices with more comprehensive criteria for
identifying complications revealed significantly increased complication
rates with mass circumcisions: 15.7% from traditional practitioners,
versus 3.8% for medically-trained professionals (Ozdemir, 1997).

We reviewed the literature and found the situation described by
Okeke (2006) to be more representative of possible outcomes. While Okeke
reports on neonatal circumcisions, a higher rate of complication than
one in which all circumcisions are performed by trained medical
practitioners is more reflective of potential outcomes and risks. A high
rate of circumcision (87%) was reported, with 9% of procedures being
performed by traditional practitioners and the remainder by doctors or
nurses. Okeke reported on complications such as redundant foreskin,
excessive loss of foreskin, skin bridges and amputation of the glans
penis. A case of severe hemorrhage requiring transfusion was also
reported. Interestingly, Okeke reported no statistically significant (p
= 0.051) difference in complication rates between nurses, doctors, and
traditional practitioners. This complication rate does not include
several more complications listed by Van Howe (2004) in his study
estimating complications and costs in a developed environment. Table 2
summarizes our cost inputs and findings.

Our updated analysis suggests that the cost per procedure could
increase up to 31% if higher rates of complications are encountered.
This first-order complication risk-weighted cost per circumcision
procedure of $73.07 may be more representative of conditions that
prevail if such a program is instituted continentally. Such an increase
in complication rates must be taken into account in evaluations of
cost-effectiveness. It must be noted that this estimate is more
conservative than the 425% lifetime incremental cost per patient
calculated by Van Howe.

Prevalence measures include everyone living with an infectious
disease and present a delayed representation of the epidemic by
aggregating the new incidences over many years. By contrast, incidence
measures the number of new infections, usually over the previous year.
Following Kahn (2006), again for the purposes of consistency, for our
study effectiveness was defined as the number of HIV infections
prevented per cohort of 1,000 men over a period of 20 years.
Effectiveness was calculated as the product of the number of
HIV-susceptible persons, the HIV-incidence rate, the protective effect
of circumcision (adjusted for risk compensation), the projection period
(in years), and an epidemic multiplier. Mathematically, this may be
represented as:

Estimates of incidence do need to take into account the quality and
reliability of data available, especially on a sub-Saharan scale. Kahn
et al. (2006) solved this problem by estimating incidence from a
steady-state model of prevalence and performing sensitivity analysis on
prevalence levels.

A key factor driving conclusions of cost effectiveness was the high
rate of HIV prevalence (25.6%) among adult men in the Gauteng province
studied (Dorrington, 2002). A critical re-evaluation of this parameter
is necessary in light of recent UNAIDS data (2007a). While prevalence
rates vary widely, a mean prevalence rate of 5% published for the
continent was used in this study as a representative value (Table 1,
above). Incidence rates may be estimated in two different ways. Using
the steady state model yields an incidence rate of 1.05 per 100
person-years (0.0105). Estimating incidence from the UNAIDS data,
accounting for the effect of the significant fraction of the population
already infected, yielded a significantly lower incidence rate of
0.0023. Both cases were modeled on the illustration in Table 3. While
derivative, the use of the Kahn model's ab initio assumptions,
corrected for UNAIDS 2007 projections, strengthened a conclusion of
Kahn's own study, where cost-effectiveness of the circumcision
procedure varied significantly with prevalence and incidence rate
assumptions.

Further sensitivity analysis was performed by conservatively
varying the protective effect of MC, which is estimated to lie between
0.34 and 0.77 by supporting studies (Auvert, 2005). We did not include
the case of statistically insignificant protective effects reported by
Millett (2007). Using incidence derived from Kahn's (2006) steady
state model and a prevalence rate of 5% (UNAIDS, 2007a), we estimated
between 52.4 and 213.2 cases of HIV prevented. Using actual UNAIDS data
for incidence yielded a predictably lower effectiveness range of 11.6
and 47.3 cases prevented. Figure 1 summarizes the significant effects
that updating these variables has on the cost effectiveness of applying
circumcision as a therapeutic prevention modality, based on the
variables above. The results suggest that significant re-thinking of the
conclusions is necessary when applying the localized findings of the
Kahn study on a continental scale.

Let us consider, however, the cost-viability of circumcision versus
that of promoting consistent condom usage. In the 44 countries that
comprise sub-Saharan Africa, there are 194 million adult males (CIA
Factbook, 2007). Of those, 9.1 million men are HIV positive (UNAIDS,
2007a) and about 62% have already been circumcised for cultural reasons
(NIAID, 2006). Therefore, approximately 69.9 million uncircumcised,
HIV-negative men remain.

Using the $73.07 risk-adjusted circumcision procedure cost
calculated by our analysis yielded an estimate of $5.1 billion for
performing the procedure for all men in the sub-Saharan region. In order
to evaluate the relative impact of this cost, we note the following:
$5.1 billion is 27 times the $188 million in 2006 UNAIDS Core
Contributions budgeted to fight HIV worldwide (UNAIDS, 2007b). Yet, this
estimate has omitted consideration of several additional costs, such as
those required to standardize safety and to educate professional and
traditional circumcision practitioners. In the sub-Saharan region, a
project of this scale would certainly involve public funding, as opposed
to private funding for procedures.

[FIGURE 1 OMITTED]

In addition, maintaining the program by circumcising all
HIV-negative males as they turn age 15 would involve additional expenses
of about $763 million per year. Rural African clinics have insufficient
supplies and training to perform aseptic circumcisions. Clinics are
currently overburdened in providing circumcision. South Africa and
Lesotho report circumcision waiting lists of 6-8 months, and Zambian
clinics are falling behind demand. Mass circumcision adoption, including
community publicity, would increase demand. Of clinics surveyed,
two-thirds did not have a selection of forceps for performing
circumcisions. Seventy percent did not have the suturing needles or
curved scissors required for adult circumcisions. Perhaps most
important, only one-third of surveyed clinics had equipment to keep
instruments sterile (Mattson, 2004). Other factors likely to hamper
circumcision implementation would include financial concerns, lack of
skilled operators, and cultural traditions (Pinock, 2007).

Given the seriousness of the HIV/AIDS crisis and the economic
situation in Africa, it is critical to determine the simultaneously
least expensive and most effective combination of preventive measures.
Since condoms and circumcision both represent male-focused
interventions, one permanent and one not, we need to compare these two
methods of prevention to illustrate the relative cost of any mass
circumcision program.

Regardless of prevalence, a comparison of the effectiveness of
circumcision to proven methods, such as use of condoms, is conclusive.
Condom usage picks up where the effectiveness range of circumcision
leaves off, with a proven effectiveness equivalent to that of preventing
pregnancies. Consistent use of condoms results in 80% reduction in HIV
incidence (Weller, 2003; de Vincenzi, 1994). Latex condoms, when used
consistently and correctly, are highly effective in preventing the
sexual transmission of HIV, the virus that causes AIDS and other sexual
transmitted infections (Feldblum, 2003; Center for Disease Control,
2002).

Condoms for free distribution cost $0.03 each (Ngwa, 2006). African
males require an average of 84 condoms per year (Myer, 2002). For the
undiscounted cost of one circumcision (with an associated limited
protective effect), a man can receive a 29-year supply of condoms and
protect himself and his partner 87-100% of the time (Mattson, 2004;
Weller, 2003).

Free condoms need only be provided to poverty-level African men
since people above the poverty line can afford to purchase them. World
Bank estimates place approximately 46% of sub-Saharan Africans below the
poverty line. As a result, a free-condom program for all adult males
would cost $224 million per year. This is in stark contrast to the $763
million annually needed to circumcise sub-Saharan African children under
age 15 alone.

Missing from the observational studies (Auvert, 2005) supporting
circumcision was the "number needed to treat," which is
conventionally provided as an effectiveness ratio for treatments. We
calculated a cumulative circumcision number needed to treat using data
from three studies and found it to be 80. Using data from a
meta-analysis (Davis, 1999), where condoms were shown to be 87%
effective at stopping HIV when used consistently, we calculated their
number needed to treat to be 1,568.

Eighty circumcisions, at a total cost of $5,845.00, would have to
be performed to prevent one HIV infection, while the use of 1,568
condoms would prevent the same infection at a cost of $47.00, making
condom use 95 times more cost-effective than circumcision. It is worth
noting that these two alternatives are not wholly comparable. Providing
condoms protects at any level of implementation. The correct use of 10
million condoms provides ten times the effect of one million condoms,
and there is no foreseeable negative repercussion of partial
implementation. However, the same is not true for circumcision.

The primary arguments against the use of condoms appear to be
inconsistency in usage, either due to inability of a sexual partner to
insist on usage (Odutolu, 2005) or religio-cultural resistance (Gyimah,
2006; Garner, 2000). However, these arguments may fail to take into
account two factors. First, as shown by Talbott (2007), when conducted
properly, cross-country regression data do not support the theory that
male circumcision is the key to slowing the AIDS epidemic. Rather, it is
the number of infected prostitutes in a country that is more significant
and robust in explaining HIV prevalence levels across countries.
Secondly, as evidenced by the examples of Uganda and Thailand, condom
use is central to the prevention of STDs, including HIV among sexually
active populations. Social marketing campaigns can play a vital role in
promoting usage, together with the increased awareness about AIDS
(Finger, 1998; Najjumba, 2003).

Circumcision can hardly be compared with a "vaccine"
against HIV, and its high cost makes it a questionable preventative.
Behavior change programs, not surgery, are more efficient and
cost-effective until such time that an even better method is developed
and approved for use. Providing free condoms is estimated to be
significantly less costly, more effective in comparison to circumcising,
and at least 95 times more cost-effective at stopping the spread of HIV
in sub-Saharan Africa. In addition, condom usage provides protection for
women as well as men. This is significant in an area where almost 61% of
adults living with AIDS are women (UNAIDS, 2007a). Before circumcision
programs are created and funds are raised, their costs should be
compared to other AIDS prevention programs so that a rational
decision-making process, to spare as many lives as possible, is
employed.

In order to evolve the best possible allocation of funds to benefit
sub-Saharan Africa, fellow investigators should direct their work
towards more clearly establishing the increased risk of male-to-female
sexually transmitted infections transmission in the post-operative
period following circumcision. In addition, a better understanding of
higher risk behavior by men following circumcision could improve
understanding of the prophylactic abilities of the procedure. Following
the suggestions of Siegfried (2005) and others, careful consideration of
ethical issues involved as well as regional and national differences in
culture, religion, and social norms should also be undertaken before
implementing such programs.

Dorrington, R. E., Bradshaw, D., & Budlender, D. (2002).
HIV/AIDS profile of the provinces of South Africa--Indicators for 2002.
Capetown: Centre for Actuarial Research, Medical Research Council and
the Actuarial Society of South Africa.